psychobabble

I am a resident in psychiatry at an academic medical center. My blog posts describe patient encounters I have had in the course of my training, both past and present. Names and identifying details have been changed. My blog conforms to the information-privacy standards detailed on http://medbloggercode.com. If you believe you have been a patient of mine and have concerns about the effects of this blog on the privacy of your medical record, please let me know and I will be happy to withdraw any offending material.

reefer madness

“Doctor, I’m afraid I might have ruined my brain.”Mr D’s wide brown eyes bore a pleading expression.He was a young law student with a cherubic dimple set in his left cheek.He had had no history of psychiatric issues until six months prior to our appointment.Then, one Saturday evening during his winter recess from school, he’d celebrated the end of the semester with friends by smoking an enormous amount of marijuanaand attending a 3-D movie.

During the movie, he told me, he had a terrifying experience.“It was as if I’d lost all of my memories.I knew nothing.I was nobody.I was starting over.” During the course of the movie he gradually regained his memories but retained a feeling of foreboding.Ever since that time he had been having episodes of déjà vu in which otherwise innocuous situations would give him the sense that he was about to be catapulted back into the memoryless state he had experienced in the movie.

Simple triggers like buying a cup of coffee at his favorite stand would give him a sudden, horrifying feeling that he had been there before, and that he knew what would happen next: He would be thrown back to the place of no memories.Or, he was having a dream and he would be forced to relive this same sequence in an endless loop, forever.The feeling would last a few minutes, and then dissipate as surely as it had come.

He’d been having experiences like this up to thirty times a day, ever since that night at the movies.They were interfering with his sleep, his work, and his love life. He hadn’t touched marijuana again since that night.Still, they weren’t going away.Finally he decided he needed help.Could I help him?He spread his hands nervously on his lap.

Marijuana use has long been associated with increases in psychotic manifestations.(For many years it was unclear whether marijuana truly tilted the brain towards psychosis, or whether marijuana was simply more appealing to the psychosis-prone brain.Earlier this year, the results of a decades-long study of marijuana use and psychosis in 3800 individuals were released (McGrath et al). They confirmed the results of two other large cohort studies that found the longer people had been using marijuana, the more likely they were to report psychotic symptoms.In addition, this most recent study analyzed sibling pairs and found that the same relationship held true – weakening the argument that some other, unknown genetic or environmental factor might be stacking the deck.)

However, Mr D.’s symptoms weren’t the classical psychotic signs of hallucinated voices or paranoid delusions.The déjà vu reminded me more of neurological oddities such as temporal lobe epilepsythan of any psychiatric syndrome.But this patient had neither a history of epilepsy nor any risk factors for seizure, and the link to marijuana use was too clear to ignore.I decided to offer Mr D. an antipsychotic – the very sort of drug we give to people who insist that the aliens are after them, or the CIA has bugged their hospital rooms, or they are the Messiah.

I made the offer tentatively, worried that the very word ‘antipsychotic’ would set alarm bells ringing in Mr D’s formerly entirely sane and rational young head.I more than halfway expected him to refuse it.But to my surprise he accepted it eagerly.“I’ve been living with this for six months,” he explained.“I just need it to stop.”

And stop it did.Two hours after his first dose, Mr D reported to me the next week, he could feel the grip of his illusions relaxing.Within a few days he went from having thirty episodes per day to having fewer than ten.After two weeks on the drug he felt he was his old self.He discontinued the medication without incident.

There is much we do not know about the neurobiological effects of marijuana.The psychoactive ingredients, cannabinoids, come in dozens of varieties whose relative proportions vary from plant to plant, presenting a complexity of Gordian proportions to the would-be researcher.

Our bodies’ cannabinoid receptors(built to respond to our own endogenous cannabinoids but, happily for college students the world over, also responsive to the herbaceous variety) are found generously distributed throughout the brain (Glass et al.), including the frontal cortical areas that are implicated in psychosis.They seem to act as local modulators, damping the strength of signals coursing through the brain’s circuits – including the frontal dopamine circuits in which hyperactivity seems to underlie psychotic episodes.Tire out the endocannabinoid ‘braking system’ by flooding it with ganja, and you have an unchecked river of dopamine signaling leading to hallucinations and paranoia (Fernandez-Espejo et al.).

Why should this cause psychosis long after the marijuana is gone from the system?I don’t know the answer, but I do know that for Mr D., the way to fix it was to use a dopamine-blocking antipsychotic.He’s doing well so far, though perhaps a bit wiser and warier.

Comments

Lawless: Yeah, that was my first thought as well, actually. But he says it was a bud crumbled in front of him, with no evidence of any other substances. More importantly though, none of his friends had any kind of issue - it seems to have been something about Mr D's physiology and the amount that he used.

i'm only an old pot head and only have anecdotal evidence to go by but there were many who had anxiety attacks following over use in the early days when kids were learning to use the drug--just like with booze. did you ask questions about whether there was substance abuse in his home? what made him want to get stoned so bad? in the old days, they'd prescribe thorazine. i had friends who carried around the pills for years when they smoked just in case they had another "attack." once they learned what they could take they didn't have another problem, just like alcohol. I remember one friend, who became a shrink, used to get paranoid, but that was because he was afraid his mentor would find out, but then one night his mentor, who was the head of a dept. at a mental hospital came over and we all got stoned together. he was a bigger pot head than any of us.

The THC levels of pot today is NOT the pot of yesteryear, from what I hear. If I choose to smoke, I am overly emotional for about 3 days thereafter, fighting off negative irrational thoughts (successfully, I might add, but why go there in the first place). Truth is, when I was a little chronic with my use, I was one messed up little girl and I lost jobs over my temperament. No, marijuana - as innocuous and fun as it may be for others - is not my friend anymore :( I love the bud, but it don't love me.

I am a long time daily user of marijuana and have known many in our Marijuana Party of Canada political party as well as the deported and now imprisoned Marc Emery. I do not smoke the weed much anymore. I can say with great certainty that this particular case is possibly a one in a million shot and perhaps the patient was not fully forthcoming or knowledgeable enough to know if indeed the marijuana was laced with another substance. I've heard this line many times " if marijuana kills , show me the bodies." I am certain that just as many may have similar effects from other legal substances including alcohol. Yes some get strange effects from marijuana , but considering the saturation of heroin, cocaine , crystal meth , and many new man made recreational drugs , the "evil" weed is a much less evil of almost all recreational drugs used today including alcohol.

I've heard marijuana users say they felt pot only enhanced what was inside of them...happy, ragers, paranoid. These people did not tend toward addiction, more like a cocktail after dinner here or there. I've also been around too many vacant heads to think it's an entirely benign substance. At an Herbal Conference in NC years ago, a Cherokee herbalist told our group that his tribe considers marijuana to be one of the more difficult drugs to break away from, and his belief was it separates us from our spiritual destiny here on Earth. Yike! Who needs that? On the other hand, it's hard to get worked up over potheads abusing when it seems more benign in comparison to other troubles, including porn addiction and junk food, in my opinion. Prescription medicine has wreaked more havoc on humanity, for all it's benefits, and I know some people are truly aided medicinally by marijuana for some conditions without risk of overdose and death. Regardless, how unfortunate for this fellow and I'm glad to hear he was able to feel back-to-normal eventually.

the problem with being a shrink is like the problem if you have a religious committment and title: the amateurs think yr supposed to be some paragon of emotional or spiritual virtue. the more experienced i get the more obvious it becomes that it's a crock of shit. in my experience the opposite is true. the so-called "experts" are the ones you gotta watch. true saints are hard to come by. i don't care what the religion is. Are you with me doc? don't u luv the bloody irony?

Ben Sen: Are you equating 'saintliness' with opposition to marijuana use here? MJ isn't god and it isn't the devil either. It's got some recreational uses, some medical uses, and a bunch of nasty long-term side effects.

That said, I'd like to see it legalized just as I would any other activity where the only victim is the user. Maybe then we could have a rational discussion about risks and benefits without everyone getting all polarized into 'pro' and 'anti.'

Then again, I get the feeling that you might be wanting to know whether I'm a pothead myself. And no I'm not, but that's mostly because it doesn't do much for me. Not because ZOMG reEfer iz teH DEVIL!!!

I personally am somewhat leaning toward legalization, because yeah, I think marijuana side effects could conceivably be less serious than alcohol. there are *zillions* of alcoholics out there. can anyone seriously argue that if we legalized marijuana [which basically is slowly happening as we speak] it would lead to more problems than alcoholism? what the real problem is, is *addictive personality* -- there are some with addictive personality disorder, I would say, and this will ripple through to all areas of their life, not merely drugs.by the way, informally I have observed in marijuana users the following, which I wonder if there is any scientific evidence fora) strong/explosive temperb) lack of ambition/motivation

Interesting post, it seems that abuse of any drug including marijuana will produce negative effects. No shock there. It could also be argued that one of the behaviors of those with mental illness is drug abuse. So it would stand to reason that those who abuse drugs would show signs of phycotic behavior, again no real shock.

There is a major incentive by both the medical industry, pharmaceutical industry, alcohol industry, law enforcement and prison industry to keep marijuana illegal. This is especially true with the metal health field who makes billions for the court mandated treatment. There are billions to be lost by all concerned so one more study that tries to ties all use to abuse is not a surprise.

Fact is if you abuse anything you will have negative effects. Most prescription drugs have a negative effect on people who abuse them, but no one in the medical profession would consider not prescribing them. And the truth is most people who try marijuana or use it do not abuse it. Not all use is abuse and I am tired as a tax payer paying billions to stop something that millions of people do because a relatively few want to be stoned all day long. There was a time in this country when those who drank to much were called drunks and resources were not wasted on them.

Because the alcoholic's drug of choice is relatively cheap and does not require crime to support their habit at least one social problem is prevented because of this particular abuse. But, crime is a major problem when billions in cash are to be made from illegal drugs. Alcohol and crime during prohibition went hand in hand. It did not stop alcohol abuse anymore than the war on drugs.

So what have we learned some people abuse drugs, if you smoke a lot of pot you will alter your mental health. So your patient smoked a lot of pot (he told y0u it was once, but I think he is lying) and was loopy for a couple of weeks. Maybe he should not do that anymore. Maybe he is an individual that has a bad reaction to marijuana, again he should not smoke it. The big difference is if he took a lot of Valium or oxycontin he would probably be dead not zoning out at the coffee shop and talking to you about it.

I've been drug, alcohol, and caffeine free since 1991. I'll be the first to insist that anyone practicing bhakti-yoga -- as a spiritual discipline or regimen -- abstain from all mind-altering substances.

Whether or not intoxication of any kind should be legal or illegal is a political and not a religious position. I personally favor an end to marijuana prohibition. And my friends who favor drug legalization, or at the very least the legalization of marijuana, agree that the only consistent anti-drug position is to personally abstain from all mind-altering substances.

A pamphlet entitled "10 Things Every Parent, Teenager and Teacher Should Know About Marijuana" produced by the Family Council on Drug Awareness tells us marijuana is not physically addictive. The 1980 Costa Rican study, the 1975 Jamaican study and the 1972 Nixon Blue Ribbon Report all concluded that marijuana use does not lead to physical dependency.

The FBI reports that 65 to 75 percent of criminal violence is alcohol-related. On the other hand, Federal Bureau of Narcotics director Harry Anslinger testified before Congress in 1948 that marijuana leads to nonviolence and pacifism.

In a message to Congress on August 2, 1977, President Jimmy Carter insisted: "Penalties against possession of a drug should not be more damaging to an individual than the use of the drug itself."

Conservatives are living in the past--in the days of "reefer madness." In a March 1979 radio broadcast, for example, Ronald Reagan said, "Somehow they (young people) never seemed to have heard the other side. Never heard, for example, that marijuana contains 300 or more chemicals and 60 of those are found in no other plant."

What Reagan failed to mention is that tobacco smoke contains over 3,000 chemicals!

Drug Enforcement Administration (DEA) Law Judge Francis L. Young wrote on September 8, 1988: "Nearly all medicines have toxic, potentially lethal effects. But marijuana is not such a substance. There is no record in the extensive medical literature describing a proven, documented cannabis-induced fatality Marijuana, in its natural form, is one of the safest therapeutically active substances known to man."

After years of suppression by the government, the truth about medical marijuana is finally coming out. Dr. Tod Mikuriya, former director of marijuana research for the entire federal government, wrote in 1996: "I was hired by the government to provide scientific evidence that marijuana was harmful. As I studied the subject, I began to realize that marijuana was once widely used as a safe and effective medicine. But the government had a different agenda, and I had to resign."

Tobacco kills about 430,700 each year. Alcohol and alcohol-related diseases and injuries kill about 110,000 per year. Secondhand tobacco smoke kills about 50,000 every year. Aspirin and other anti-inflammatory drugs kill 7,600 each year. Cocaine kills about 500 yearly alone, and another 2,500 in combination with another drug. Heroin kills about 400 yearly alone, and another 2,500 in combination with another drug. Adverse reactions to prescription drugs total 32,000 per year, while marijuana kills no one.

A November 4, 2002 Time/CNN Poll found that eighty percent of those polled felt marijuana should be legal only for medicinal purposes. 72 percent felt recreational users should get fines rather than jail time, which is essentially decriminalization.

The complete legalization of marijuana was favored only by 34 percent of respondents, but this figure is twice as large as it was in 1986. Marijuana is safer than alcohol and tobacco, and our drug laws should reflect this reality.

According to a 2003 Zogby poll, two of every five Americans say “the government should treat marijuana the same way it treats alcohol: It should regulate it, control it, tax it, and only make it illegal for children.”

Close to 100 million Americans, including over half of those between the ages of 18 and 50, have tried marijuana at least once. Military and police recruiters often have no alternative but to ignore past marijuana use by job seekers.

In 1996, California voters passed a law to regulate medical marijuana within the state. In 2000, voters in California approved an initiative allowing people who are arrested for simple possession of drugs to go through a rehabilitation program rather than through the court process that would result in prison. Since the program began, most agree it has been very successful. It results in less recidivism and is considered cheaper than imprisonment.

Richard Posner, Chicago's chief judge of the 7th U.S. Circuit Court of Appeals and one of the nation's leading legal scholars, says marijuana use should be legalized as a way of reducing crime. Posner, a Reagan administration appointee once described by American Lawyer magazine as “the most brilliant judge in the country,” explained his views on marijuana in The Times Literary Supplement, a British publication, and in later interview:

“It is nonsense that we should be devoting so many law enforcement resources to marijuana," says Posner. "I am skeptical that a society that is so tolerant of alcohol and cigarettes should come down so hard on marijuana use and send people to prison for life without parole.”

Posner is the highest-ranking judge to publicly favor the repeal of marijuana laws. Several judges of the federal district court, a level lower than the appeals court, have made similar calls, including Robert Sweet of New York and James Paine of Florida, both Carter Administration appointees.

New York University law professor Burt Neuborne said it's significant that “one of the leading intellectuals in the judicial system recognizes that the laws don't seem to be working well.”

Posner and other federal judges have complained that sentencing guidelines force them to give unjustly severe prison sentences to relatively minor drug offenders. Says Posner: “Prison terms in America have become appallingly long, especially for conduct that, arguably, should not be criminal at all. Only decriminalization is a sure route to a lower crime rate. It is sad that it appears so far below the horizon of political feasibility.”

Rufus King, a Washington, DC lawyer who has served on the President's Commission on Law Enforcement and the Administration of Justice, calls the drug war, “A worthless crusade.”

According to King, drug use is a social problem, not a law enforcement problem. He observes: “Cigarette use is declining through changes in cultural values in the population. Like most smokers and alcoholics, most users of illegal drugs poison themselves because they want to be intoxicated. No human force can do them much good until they want help.”

King is optimistic that the current anti-drug hysteria will subside, and responsible and reasonable drug law policies will be adopted.

Dissenting from the Supreme Court ruling on the suspension of an Alaskan student for waving a banner -- "BONG HITS 4 Jesus" -- at a high school event, Justice John Paul Stevens took the long view:

"...the current dominant opinion supporting the war on drugs in general, and our anti-marijuana laws in particular, is reminiscent of the opinion that supported the nationwide ban on alcohol consumption when I was a student. While alcoholic beverages are now regarded as ordinary articles of commerce, their use was then condemned with the same moral fervor that now supports the war on drugs...

"...just as Prohibition in the 1920's and early 1930's was secretly questioned by thousands of otherwise law-abiding patrons of bootleggers and speakeasies, today the actions of literally millions of otherwise law abiding users of marijuana, and of the majority of voters in each of the several states that tolerate medicinal uses of the product, lead me to wonder whether the fear of disapproval by those in the majority is silencing opponents of the war on drugs."

The Washington Post, July 26, 2007, reported: "Stevens compared the current marijuana ban to the abandoned alcohol ban and urged a respectful hearing for those who suggest 'however inarticulately' that the ban is 'futile' and that marijuana should be legalized, taxed and regulated instead of prohibited."

And polling shows that a growing number of Californians think legalization is the right solution. A field poll in April 2009 showed 56 percent support for legalization. Internal campaign polling in March 2009 found 44 percent support among possible California voters in non-presidential elections. This was followed by an August internal poll that found 52 percent support possible by voters in November 2010.

Number of people arrested for a marijuana law violation in 2008: 847,864.

Percent of Americans who favor the complete legalization of marijuana: 44%.

Percent of Americans who favor legalization of medical marijuana: 72%.

Number of states that allow the medicinal use of marijuana: 14.

Estimated annual revenue that California would raise if it taxed and regulated the sale of marijuana: $1,300,000,000.

As of July 27, 2010, 52% of California voters support Proposition 19 to legalize and tax cannabis within the state, while only 36% are against it.

Ponti, I would not disagree, long term abuse of almost any drug including marijuana can lead to more serious mental illness. Some would advocate marijuana is harmless and for most who do not abuse it that may be true. That is true of those who do not abuse alcohol, but those who do abuse either will continue to develop increased metal illness. My point is that (from my experience) metal illness and drug abuse go hand in hand. It is sort of the chicken and the egg argument. Did the marijuana cause the increased effects of mental illness or because the person in question because of their mental illness became an abuser of drugs and because of it their mental illness became more serious with increased symptoms.

I think the biggest resistance to medical marijuana is because it gained popularity first as a recreational drug and later the medical benefits became known, but in the eyes of the established medical community it is considered a recreational drug only. Many pharmaceutical drug are abused at even higher rates than marijuana, but since they were first introduced for medical use the medical community does not consider the drug to be dangerous only those who abuse it. It is the opposite with marijuana, the drug is considered the danger not the abuse of the drug.

The fact that one cannot OD on marijuana is sort of a two edged sword. Granted no one ends up in the emergency room dying of marijuana over use, but long term negative effects of abuse can be the same as any drug.